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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical evaluation and claims processing, with a strong focus on compliance with laws and regulations. Proficient in analyzing medical claims and providing training and support to team members.
Highest-signal resume keywords
Registered Nurse (RN)Clinical EvaluationClaims ProcessingUtilization ManagementAnalytical Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Information ReviewData InterpretationClaims EvaluationRegulatory ComplianceConfidentiality Adherence
Soft Skills
Training and MentoringCommunicationProblem-Solving
Tools & Technologies
Microsoft SuiteClinical Systems
Certifications & Qualifications
Nursing Degree (RN)Associates Degree in Nursing
Industry Keywords
Medical ClaimsClinical PoliciesFraud DetectionLegislation Compliance
About the role
Key responsibilities & impact- Review and evaluate clinical information and documentation
- Interpret data from clinical records or systems and apply appropriate clinical criteria and policies to post-service claims
- Coordinate clinical resolutions independently, with clinician/MD support as required
- Evaluate claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits
- Navigate multiple system applications and outreach to internal departments or providers as needed
- Act as a resource for customer service and claims processing teams
- Train new staff and provide cross-training to existing team members
- Identify trends and provide feedback to leadership regarding discrepancies or potential fraudulent activities
- Remain current with applicable laws, regulations, and internal workflows to ensure compliance
- Protect member information by adhering to confidentiality policies
Requirements
What you’ll need- Nursing degree (RN)
- Associates Degree in Nursing required
- A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience
- Strong analytical skills to assess medical claims
- Computer proficiency, Microsoft Suite
- Utilization Management experience preferred
- Bachelor of Science and Nursing preferred
- Ability to comply with applicable laws, regulations, company policies, procedures, confidentiality requirements, and state-specific requirements
Benefits
Comp & perks- CVS Health bonus, commission or short-term incentive program in addition to the base pay range
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility